MEDICAL RECORD FORM

Child’s Name                                                                    Date of Birth _____________________

Father’s Name                                                                   Occupation ______________________

Mother’s Name                                                                 Occupation _______________________

Address                                                                             City                      State         Zip ______

Phone (Home)                                (Work)                                      (Cell/Beeper) ______________

Family Doctor                                                                  Phone ___________________________

Emergency Contacts if parents are unavailable:

1st                                                          _ Relation                     Phone Number _______________

2nd                                                          _Relation                     Phone Number _______________

INSURANCE INFORMATION

Company Name___________________________________ Policy #______________________

Company Phone #_________________________________ Group #______________________

                                              MEDICAL QUESTIONNAIRE

Answer either “Yes” or “No.” If “Yes,” explain under “Remarks.”

                                                   YES/NO                                                    YES/NO

Heart problems

 

Sinus condition

 

Lung problems

 

High blood pressure

 

Allergies/Asthma

 

Fainting/Dizziness

 

Shortness of breath

 

Skin infections

 

Hearing/ear problems

 

Food Allergies

 

Vision/eye problems

 

Medicine/Drug allergies

 

Diabetes

 

Wear contacts and/or glasses

 

Appendix removed

 

Special diet

 

Hospitalized in the past year?__________Surgery in the past year?_________

Any exposure to Hepatitis/infectious diseases in the past 6 months?_________

Any disorder preventing strenuous activity?____________________________

Any daily medications? _________ If yes, please give details below.

REMARKS/CONCERNS: ___________________________________________

__________________________________________________________________

__________________________________________________________________

                        MEDICAL TREATMENT AUTHORIZATION

      I, as parent or guardian of the aforementioned child, understand that in the case of a medical emergency, every effort will be made to see that I am notified. However in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill.

      I authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

      I understand that the Royal Rangers will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as parent/guardian..

      I agree to notify the church in the event of any health changes which would restrict my child’s participation in any normal youth or Royal Ranger activity.

 

                                                                                                            __________________

      (Signature Parent/Guardian)                                                                        (Date)

 

                                                             Revised:  September 2005